The mandate requires any therapy claims for combined speech-language pathology and physical therapy that reach $3,700 to be reviewed for medical necessity. The $3,700 threshold includes the total allowed charges for services furnished by independent practitioners and all institutional services under Medicare Part B (i.e., hospital outpatient departments, skilled nursing facilities, critical access hospitals).

The manual medical review applies to all Part B outpatient therapy settings, including:

Review Process

For services rendered on or after February 28, 2014, Medicare Recovery Audit Contractors (RACs) will conduct the medical reviews through post-payment review. Postpayment review occurs when the services have been rendered, claims are submitted, the claim is adjudicated for payment, and the claim is paid. Following are the steps taken in the review process.

The MAC will flag the claims that meet $3,700 threshold and then send an Additional Document Request (ADR) to the provider requesting that the documentation be sent to the Recovery Auditor. The process for submitting the documentation is to be determined by the MAC and the Recovery Auditor.

The Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision. CMS did not indicate a timeframe for notification to the provider.

Postpayment may result in no change to the initial payment to the provider or may result in a "revised determination" that would require the provider to pay back monies for services determined to be "not reasonable or necessary." The provider will be notified of any payment determination, and if necessary, be given the options of

ASHA Contacts

Submit a sample denial:MMR@asha.org. ASHA has created a dedicated manual medical review e-mail address (MMR@asha.org) where members are encouraged to send de-identified documents and cases, including denial letters, for presentation to CMS.Before e-mailing, please make sure to remove all patient identification data and include communication from the MAC or RAC.